vital figr

A B ,

left drain
Presenting my patient, Puan Fatimah bt Mohamad, 61 y/o Malay woman , a housewife / with u/l DM, HPT, HPL presented with a left breast nama op
swelling at nipple area since 3 years ago. Regarding the swelling, it located near the nipple area, initially claimed size about 5 cent and became
progressively bigger about 50 cent for past few months. Patient claimed it was hard, painless , and her left nipple became retracted however
denied any skin changes such as no redness/dimpling of skin and denied any nipple dischrge.

Otherwise, patient also had no fever, no LOA, LOW and denied ny metastatc sx such as bone pain/sob/weakness.
On further questioning, patient had menarche at the age 14 y/o, had menopause at the age of 58 y/o. Pt had 5 children, had late childbirth which
was at at the age of 49 y/o. She breasfed all of her children up until 2 y/o. Pt claimed had hx taking OCP over the counter #
for at least 2 years
(unsure ? Duration) . Patient denied any family hx of breast cancer running in her family however claimed her eldest son had passed away at the
age of 24 years/o due to untreated bone cancer (unsure details).

Due to concern of the condition, she decided to seek opinion from doctors during her routine f/u ¥
for DM+HPT in Oct last year. Pt claimed doctor
at KK did thorough breast examination and referred her case to SOPD HSNZ for further mx.

Patient went to seek tx at SOPD HSNZ in Jan this year. She did US + mammogram of breast and was told suspicious of cancer over left breast
and was told to proceed with biospy . She was told the HPE result from the biopsy taken showed evidence of left breast invasive ca which
needed further ct scan. She did ct scan in feb this year and was told no evidence of metastases and had to proceed with operation for removal
of the left breast which scheduled in 18/3/24 which was yesterday.

On physical examination,
General inspection
She is a middle aged woman with big medium built body size lying comfortable in supine position with head supporting with one pillow. She was
alert, conscious well orientated to time place person. She looks well, not pain

BP :
PR:
SpO2
T

General examination:
Hand: her palm was dry, warm, pink, crt < 2 sec. Radial pulse 80 bpm with regular ryhtm and good volume
Eyes:The conjuctiva as pink (no pallor), sclera was white (no jaudice)
Mouth: oral hygiene good, tongue moist (good hydration status), no central cyanosis
Neck: no neck swelling/ cervical palpable LN
LL: no ankle edema

Breast examination
Inspection:
Left breast was bigger compared right size
There was presence of nipple retraction over the left breast
There was no other skin changes such as no erythema , skin dimpling, no skin discoloration, no eczema-like skin or ulceration for both sides
There was no nipple dc
There was no visible nodules around axilla

Palpation:
There was presence of a single lump at 3 o clock over left breast veto areolar area
The lump was approximately 5cmx5cm in size, round in shape, smooth surface, hard in consistency, non tendr, well defined margin, fixed to
skin/u/l pectoralis major
There was a single palpable axillary LN at left side of axilla measurig 1cmx1cm non tender hard in concictency ,mobile

Systemic examination
Respiratory examination: No evidence of pleural effusion: Equal a/e both sides, lungs clear (stony dullness, reduced a/e)
Back examination: no spine tenderness
Abdomen examination: no jaundice, no ascites , no organomegaly
②neurological deficit that might indicates mets to brain (weakness)
CNS examination: no
①gas 811
intact
③ all Cox
 In summary, my patient is 61 years old, Malay woman with u/l DM, HPT, HPL p/w left sided breast swelling for past 3 years which was
progressively bigger in size for past few months with left nipple retraction .She had late menopause (58 y/o) and late childbirth (49 y/o) with
hx using otv OCP (unsure duration) and had family hx of bone malignancy (her eldest son).

On breast examination, There was presence of nipple retraction over the left breast, there was no other skin changes such as no erythema ,
skin dimpling, no skin discoloration, no nipple dc
area
ktwareocar
There was presence of a single lump at 3 o clock over left breast, meausring 5cmx5cm in size, round in shape, smooth surface, hard in
consistency, non tendr, well defined margin, fixed to skin/u/l pectoralis major
There was a single palpable axillary LN at left side of axilla measurig 1cmx1cm non tender hard in concictency ,mobile

Systemic examination unremarkable

My provisional dx

Left breast carcinoma

+ve
Advanced age
Painless lump in left breast (progressively increasing in size)
Nipple retraction
Risk fx
-late childbirth, late menopause, hx of taking OCP, family hx malignancy
From PE findings

-ve
No mets sx
No constitutional sx
Hx of BF (protecting fx)
Multiparous

nipple (destructed -
eaemliakle.fm)
invoked
DDX ④ v11 palpable breast lump

① 1. Pagets disease ,

② 2. Phyllodes tumor

+ve: over 40 y/o, breast lump, large tumor, no mets sx (phyllodes tumor doe not metastasize)
-ve: immobile, no skin necrosis

③ 3. Fibroadenoma

+ve: painless breast lump, no skin changes, well defined mass, no mets sx
-ve: not mobile (more mobile) advanced age, hard in consistency (more to firm), presence of LN

④ 4. Breast cyst

+ve: painless breast lump, solitary lesion,

-ve: usually around menopause age
 INVESTIGATION

US of breast 14/1/24
Apt = Tuple powtil
911124

ER ,
PR tie

Her
2 It

(Triple )
tie

Wbc = 7- 9
,
hb 14 , Plt 276

Ulla 2
4.7 , Ha 119 ,
K g. 7 Cl 99 ,
Cr
69
,

pt 115 , inv 1.07 , aptt 29.8

Mammogram 1411124
left breast on T4bN1M×

CT TAP 712124
① ③
 M①
④ us +

I
mammogram quay
Patient was admitted on 17/3/24 one day prior op Twatbioph : Triple tie

On 18 /3/24 , she underwent left modified radical mastectomy t

①
Intraop finding:
start on letwwle
2 'S
my
OD -

23/1/24
until a-

③ Patient currently, day 2 post op of left modified radical mastectetomy . Patient currently tolerating orally, no nausea/vomiting, ambulating
with wheelchair, pain tolerable over the operation site.
TAP

Drain A CTTAD 7121M

④ Drain B
prior

② I -1dg op
.

LAMAN 1813124

④
If no nets → for left
mnm

If nets -1 AI t byxnng